For all my Canadian readers (and any international readers planning to attend), here just a quick reminder that the deadline for early bird discount registration for the upcoming 4th Canadian Obesity Summit in Toronto, April 28 – May 2, ends March 3rd.
To anyone who has been at a previous Canadian Summit, attending is certainly a “no-brainer” – for anyone, who hasn’t been, check out these workshops that are only part of the 5-day scientific program – there are also countless plenary sessions and poster presentations – check out the full program here.
To register – click here.
It would hardly come as a surprise to regular readers that I would be delighted to see the Edmonton Obesity Staging System featured quite prominently in the article on obesity management by Dietz and colleagues in the 2015 Lancet series on obesity.
Here is what the article has to say about EOSS:
“The Edmonton obesity staging system (EOSS) has been used to provide additional guidance for therapeutic interventions in individual patients (table 1). EOSS provides a practical method to address the treatment paradigm. In principle, EOSS stages 0 and 1 should be managed in a community and primary care setting. Recent data from the USA suggest that 8% of patients with severe obesity (BMI ≥35 kg/m²) account for 40% of the total costs of obesity, whereas the more prevalent grade 1 obesity accounts for a third of costs. These findings suggest that greater priority should be accorded to EOSS stages 3 and 4, resulting in greater focus on pharmacological and surgical management delivered in specialist centres.”
These recommendations are not surprising, as EOSS was specifically designed to provide a much better representation of how “sick” a patient is rather than just how “big” she is.
This is why EOSS has now found its way not just into the 5As of Obesity Management framework of the Canadian Obesity Network but also into the treatment algorithm of the American Society of Bariatric Physicians.
To download a slide presentation on how EOSS works click here.
The title of this post may sound like a “no-brainer”, but the research literature on the long-term health benefits of weight loss from longitudinal intervention studies in people with severe obesity is much thinner than most people would expect.
Thus, a new study from our group, that looks at the relationship between changes in body weight and changes in health status over two years in patients with severe obesity enrolled in the Alberta Population-based Prospective Evaluation of the Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study, published in OBESITY, may well be of considerable interest.
As described previously, APPLES is a 500-patient cohort study in which consecutive, consenting adults with BMI levels > 35 kg/m2 were recruited from the Edmonton Adult Bariatric Specialty Clinic. The 500 patients enrolled were between 18 and 60 years old and were either wait-listed (n=150), beginning intensive medical treatment (n=200) or had just been approved for bariatric surgery (n=150). Complete follow-up data at 24 months was available for over 80% of participants.
At study enrollment, the proportion of patients who reported >2 and >3 chronic conditions was 95.4% and 85.8%, respectively. The most common single chronic conditions at baseline were joint pain (72.2%), anxiety or depression (65.4%), hypertension (63.4%), dyslipidemia (60.4%), diabetes mellitus (44.6%), gastrointestinal reflux disease (35.4%), and sleep apnea (33.5%).
After 2 years, just over 50% of participants had maintained a weight loss > 5%, with a mean weight change for the entire cohort of about 13 kg.
Losing > 5% weight was associated with an almost 2-fold increased likelihood of reporting a reduction in multimorbidity at 2-year follow-up, whereby outcomes varied between treatment groups: in the surgery group, the top three chronic conditions that decreased in prevalence over follow-up were sleep apnea (43% at baseline vs. 25% at 2 years,), dyslipidemia (60% vs. 47%), and anxiety or depression (59% vs. 47%); in the medically treated group anxiety or depression (69% vs. 57%) and joint pain (77% vs. 67%); and none in the wait-listed group.
As expected, any reduction in multimorbidity was associated with a clinically important improvement in overall health status.
In summary, this paper not only documents the considerable multimorbidity associated with severe obesity, it also documents the clinically important improvement in health status associated even with a rather modest 5% weight loss over 2 years in these individuals.
Anyone interested in the issue of obesity and cardiovascular disease may want to get a copy of the latest edition of the Canadian Journal of Cardiology, which includes a number of review articles and opinion pieces on a wide range of issues related to obesity and cardiovascular disease.
Here is the table of contents:
Lim SP, Arasaratnam P, Chow BJ, Beanlands RS, Hessian RC: Obesity and the challenges of noninvasive imaging for the detection of coronary artery disease.
Garcia-Labbé D, Ruka E, Bertrand OF, Voisine P, Costerousse O, Poirier P. Obesity and Coronary Artery Disease: Evaluation and Treatment.
Lovren F, Teoh H, Verma S. Obesity and Atherosclerosis: Mechanistic Insights.
Sankaralingam S, Kim RB, Padwal RS. The Impact of Obesity on the Pharmacology of Medications Used for Cardiovascular Risk Factor Control.
Piché MÈ, Auclair A, Harvey J, Marceau S, Poirier P. How to Choose and Use Bariatric Surgery in 2015.
Poirier P, McCrindle BW, Leiter LA. Obesity-it must not remain the neglected risk factor in cardiology.
Lang JJ, McNeil J, Tremblay MS, Saunders TJ. Sit less, stand more: A randomized point-of-decision prompt intervention to reduce sedentary time.
Yesterday, saw the release of new Clinical Practice Guidelines from the Canadian Task Force on Preventive Health Care to help prevent and manage obesity in adult patients in primary care.
Similarly to the Endocrine Society’s Guidelines for the pharmacological treatment of obesity (see yesterday’s post), the authors use a GRADE system to rank and rate their recommendations.
Key recommendations are summarized as follows:
- Body mass index should be calculated at primary health care visits to help prevent and manage obesity.
- For normal weight adults, primary care practitioners should not offer formal structured programs to prevent weight gain.
- For overweight and obese adults health care practitioners should offer structured programs to change behaviour to help with weight loss, especially to those at high risk of diabetes.
- Medications should not routinely be offered to help people lose weight.
Virtually all of these recommendations are supported by evidence that is rated between moderate to very low, which essentially leaves wide room for practitioners to either do nothing or whatever they feel is appropriate for a given patient.
The guidelines do not discuss the role of bariatric surgery (arguably the most effective treatment for severe obesity) and make no recommendations for when this should be discussed with patients.
The rather subdued recommendations for the use of medications is understandable, given that the only prescription medication available for obesity in Canada is orlistat (why the authors chose to also discuss metformin, which is not indicated for obesity treatment, is anyone’s guess).
Overall, the reader could easily come away from these guidelines with a sense that obesity management in primary care is rather hopeless, given that behavioural interventions are modestly effective at best (which is probably why the authors recommend that these not be routinely offered to patients at risk of weight gain).
Indeed, it is hard to see how primary care practitioners can get more enthusiastic about obesity management given this rather limited range of treatment options currently available to Canadians.
If there is anything to take away from these guidelines, it is probably the simple fact that we desperately need more effective treatments for Canadians living with obesity.